NPIMap

Organization Active NPI

Oral & Maxillofacial Surgery of Tyler, PC

  • Oral and Maxillofacial Surgery (Dentist)
  • Tyler, TX
National Provider Identifier
1154493922
Registry record updated Jul 16, 2008
On this page

Key facts

NPPES NPI Registry
Primary specialty
Oral and Maxillofacial Surgery (Dentist)Taxonomy code 1223S0112X
License
10456 & 17107 Issued in TX
Legal business name
ORAL & MAXILLOFACIAL SURGERY OF TYLER, PC
Practice address
700 Olympic Plaza Cir Ste 412
Tyler, TX 75701-1952
Phone
(903) 595-5186
Fax
(903) 595-5240
NPI assigned
Nov 15, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 16, 2008

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Jerri G. Grace
Title
Office Manager
Phone
(903) 595-5186

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Oral and Maxillofacial Surgery (Dentist)Group: 193400000X SINGLE SPECIALTY GROUP 1223S0112X 10456 & 17107 TX Primary

Addresses

Primary practice location

700 Olympic Plaza Cir Ste 412
Tyler, TX 75701-1952

Mailing address

700 Olympic Plaza Cir Ste 412
Tyler, TX 75701-1952
Phone (903) 595-5186

Other identifiers 1

IdentifierTypeStateIssuer
080858601MedicaidTX

Other names 1

  • Olympic Plaza Oral & Maxillofacial Surgery Assoc. Former legal business name

National Provider Directory

National Provider Directory

Locations

700 Olympic Plaza Cir
Ste 412
Tyler, TX 75701
Phone (903) 595-5186

Practitioners & affiliated clinicians

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1163548800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1216166400000",
    "number": "1154493922",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "700 OLYMPIC PLAZA CIR STE 412",
            "city": "TYLER",
            "state": "TX",
            "postal_code": "757011952",
            "telephone_number": "903-595-5186",
            "fax_number": "903-595-5240"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "700 OLYMPIC PLAZA CIR STE 412",
            "city": "TYLER",
            "state": "TX",
            "postal_code": "757011952",
            "telephone_number": "903-595-5186",
            "fax_number": "903-595-5240"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ORAL & MAXILLOFACIAL SURGERY OF TYLER, PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-11-15",
        "last_updated": "2008-07-16",
        "status": "A",
        "authorized_official_last_name": "GRACE",
        "authorized_official_first_name": "JERRI",
        "authorized_official_middle_name": "G.",
        "authorized_official_title_or_position": "OFFICE MANAGER",
        "authorized_official_telephone_number": "903-595-5186"
    },
    "taxonomies": [
        {
            "code": "1223S0112X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dentist, Oral and Maxillofacial Surgery",
            "state": "TX",
            "license": "10456 & 17107",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "080858601",
            "state": "TX"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Olympic Plaza Oral & Maxillofacial Surgery Assoc.",
            "code": "4",
            "type": "Former Legal Business Name"
        }
    ]
}

Other providers in Tyler, TX

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 16, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.